Suicide in Older Adults: How Do We Detect Risk and What Can We Do About It?

Older adults have higher rates of suicide than younger adults in many industrialized nations.1,2 Any discussion of this increasingly important issue must be qualified by 2 caveats. First, the age at which a person is considered to be "older" varies across cultures and from one era to the next. Age 65 is the traditional but arbitrary retirement age in many industrialized nations. This group is heterogeneous, but few studies have determined whether the clinical risk markers for persons aged 65 to 70 years are identical to those aged 80 to 85 years.

Second, in many nations, rates of at tempted suicide are highest in younger women,3 but rates of completed suicide are highest in older men.1,2 Just as the demographics of nonlethal and lethal suicide attempts are different, their clinical risk markers probably differ.4,5 The extent to which research on at tempted suicide might inform efforts to prevent completed suicide is arguable.6 When researchers conflate suicidal behavior and completed suicide, they are likely to reach inaccurate con clusions that could misdirect treatment and prevention efforts.6 In this article we focus primarily on completed suicide.

Demographics of suicide Age, sex, race, and national differences in suicide rates
As shown in the Figure 1, suicide rates for men in the United States increase with age, but women's rates peak in midlife and remain stable or decline slightly thereafter. Suicide rates in white men aged 85 years and older are almost 6 times the nation's age-adjusted rate. In the United States, whites have higher rates than blacks across the life span.

In the United States, the mid-Atlantic states and New England have lower suicide rates than do the mountain states. Acknowledging minor annual variations, the crude rates in the mountain states are nearly twice those of the mid-Atlantic region. These differences could be attributed in part to the density of available mental health services.7 Other possible explanations include differences in religious practice and de nomination, ethnicity, community cohesiveness or social capital, and availability of firearms.

It should not be assumed that all risk factors for suicide are similar in strength across sociodemographic groups or geographic locales. For example, alcohol dependence is a more potent risk factor in Sweden than it is in France,8 and it might well be a more potent driver of risk in one region of the United States than in another. Despite the need for demographically and geographically sensitive risk assessments, available data are of little guidance to the clinician.

Marital status
Durkheim9 reported that suicide rates for people who are single, divorced, or widowed are higher than for married people. Widowhood is a more potent risk factor for suicide in younger people than in older adults,10 perhaps because the death of a spouse is often an un expected event in young adulthood.11 Nonetheless, widowhood confers risk in older adults as well. The clinical as sessment of marital status should in clude inquiries about current marital status, relationship satisfaction, presence of conflict, and past marital history. Married individuals with previous histories of divorce or widowhood might be at heightened risk, although there are no firm data on this issue.

Living arrangements
Residential choice is determined by local cultural and subcultural norms, housing prices, and population density. Therefore, it is not surprising that some studies indicate that living alone does not confer suicide risk12,13 and others suggest that it does.14 Living alone might confer risk in some contexts be cause it increases loneliness and com promises adherence to mental health treatments. Living with others may amplify risk if these arrangements engender family discord.

After determining whether a patient lives alone, the clinical interviewer should follow up with questions about recent changes in living arrangements, reasons for any changes, and satisfaction with living arrangements.

Socioeconomic status
Our data suggest that older adults who have less education15 and lower income16 may be at increased risk. Reasons for this disparity include less access to good-quality and affordable health care; subtle bias on the part of service providers; lower levels of mental health literacy; more stigmatized attitudes toward the receipt of mental health care; and chronic exposure to life event stress ors and chronic strains, such as the daily consequences of poverty.17,18 By itself, poor access to good-quality services probably could not explain the socioeconomic disparity as observed in a study of older patients receiving anti depressant treatment from a university-affiliated tertiary care facility because access to care in this study was controlled by design.19

The assessment of socioeconomic status should include questions about educational attainment, annual household income, changes in income, reasons for any changes in income, and sat isfaction or dissatisfaction with in come. Socioeconomic status is often tied to neighborhood influences, which could, in turn, independently increase risk of poor mental health outcomes.20 Clinicians may wish to inquire about perceived neighborhood poverty or affluence, safety, and the patient's comfort with the surrounding neighborhood.